Pharyngeal Ph Monitoring Better Predicts a Successful Outcome for Extra-Esophageal Reflux Symptoms After Anti-reflux Surgery

Stephanie G Worrell, MD, Steven R DeMeester, MD, Daniel S Oh, MD, Jeffrey A Hagen, MD

DEPARTMENT OF SURGERY, KECK SCHOOL OF MEDICINE, UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CA

INTRODUCTION: Gastroesophageal reflux disease can be associated with extra-esophageal symptoms (hoarseness, cough, asthma, and globus). However, these symptoms may have a multi-factorial etiology. Proximal pH monitoring has been proposed as a means of identifying patients where reflux is the cause of the extra-esophageal symptoms. To date, it has not been convincingly shown that proximal pH monitoring accurately predicts a satisfactory surgical outcome. Pharyngeal pH monitoring may be a more accurate alternative. The aim of this study was to determine whether proximal esophageal or pharyngeal pH monitoring better identified patients with extra-esophageal symptoms that improved after anti-reflux surgery.

METHODS: A retrospective chart review was performed to identify all patients who had anti-reflux surgery for extra-esophageal symptoms and had pre-operative esophageal and pharyngeal pH monitoring. Esophageal pH monitoring consisted of either a Bravo capsule or dual probe catheter. Pharyngeal pH monitoring was performed using the Restech® system. A composite score was used to define an abnormal result with each test. Post-operative outcome was assessed at a mean of 20 months. A successful outcome was defined as improvement or resolution of extra-esophageal symptoms.

RESULTS: There were 18 patients (men=6 and women=12) with extra-esophageal symptoms such as hoarseness (67%), cough (61%), asthma (33%), and globus (33%). Typical reflux symptoms were also present in 15/18 patients [dysphagia (39%), regurgitation (44%), and heartburn (67%)]. Distal pH monitoring was abnormal in 13 patients (72%). Anti-reflux surgery led to a successful outcome in 12 patients (67%.) The presence of typical reflux symptoms in addition to extra-esophageal symptoms did not significantly increase the likelihood of a successful outcome. The relationship between results of proximal esophageal and pharyngeal pH monitoring and a successful outcome are shown (Table). Restech better identified patients with extra-esophageal symptoms who had a successful outcome with anti-reflux surgery (4/9 based on abnormal proximal probe versus 11/12 based on abnormal Restech, p<0.05). In two patients with a successful outcome Restech was the only positive test.

CONCLUSION: In patients with extra-esophageal reflux symptoms, proximal pH monitoring failed to identify more than half of the patients who had a successful outcome after anti-reflux surgery. In contrast, an abnormal Restech pH test was present in more than 90% of patients with a successful outcome. Further, a negative Restech study more reliably indicated the absence of reflux induced extra-esophageal symptoms. Our results indicate that Restech pharyngeal pH monitoring should be utilized in the evaluation of patients with extra-esophageal symptoms that may be associated with reflux disease.

Session: Podium Presentation

Program Number: S061